Required target margins for image-guided lung SBRT: Assessment of target position intrafraction and correction residuals

Purpose: With increased use of stereotactic body radiotherapy (SBRT) for early-stage lung cancer, quantification of intrafraction variation (IFV) is required to develop adequate target margins. Methods and Materials: A total of 409 patients with 427 tumors underwent 1593 fractions of lung SBRT between 2005 and 2010. Translational target position correction of the mean target position (MTP) was performed via onboard cone-beam computed tomography (CBCT). IFV was measured as the difference in MTP between the post-correction CBCT and the post-treatment CBCT and was calculated on 1337 fractions. Results: Mean IFV-MTP was 0.0 +/- 1.7 mm, 0.6 +/- 2.2 mm, and - 1.0 +/- 2.0 mm in the mediolateral (ML), anteroposterior (AP), and craniocaudal (CC) dimensions, and the vector was 3.1 +/- 2.0 mm; 67.8% of fractions had an IFV vector greater than 2 mm, and 14.3% greater than 5 mm. Weight, excursion, forced expiratory volume in the first second of expiration, diffusing capacity of the lung for carbon monoxide, and treatment time were found to be significant predictors of IFV-MTP greater than 2 mm and 5 mm. Significant differences in IFV-MTP were seen between immobilization devices with a mean IFV of 2.3 +/- 1.4 mm, 2.7 +/- 1.6 mm, 3.0 +/- 1.7 mm, 3.0 +/- 2.5 mm, 3.3 +/- 1.7 mm, and 3.3 +/- 2.2 mm for the body frame, hybrid device, alpha cradle, body fix, wing board, and no immobilization, respectively (P < .001). Estimated required target margins for the entire cohort were 4.3, 6.1, and 6.0 mm in the ML, AP, and CC dimensions, with differences in margins based on immobilization. Conclusions: IFV is dependent on several factors: immobilization device, treatment time, pulmonary function, and bodyweight. These factors are responsible for a significant portion oftarget margins with a mean IFV vector of 3 mm. Target margins of 6 mm or greater are required to encompass IFV in all dimensions when using four-dimensional CT with CBCT without respiratory gating or compression. (C) 2013 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.